Preterm Infants

Terms You Should Know

Apneic Spells Cessation of breathing for more than 20 seconds or accompanied by cyanosis or bradycardia.
Bronchopulmonary Dysplasia Chronic pulmonary condition in which damage to the infant's lungs requires prolonged dependence on supplemental oxygen.
Compliance Stretchability or elasticity of the lungs and thorax that allows distention without resistance during respirations.
Containment A method of increasing comfort in infants by swaddling or other means to keep the extremities in a flexed position near the body.
Corrected Age Gestational age that a preterm infant would be if still in utero. Also may be called developmental stage; the chronological age minus the number of weeks the infant was born prematurely.
Enteral Feeding Nutrients supplied to the gastrointestinal tract orally or by feeding tube. Usually begun within the first few days because they may improve intestinal growth and maturity. Bowel sounds should be present and infant in relatively stable condition.
Extremely Low-Birth-Weight Infant (ELBW) An infant weighing 1000 g (2 lb, 3 oz) or less at birth.
Intrauterine Growth Restriction (IUGR) Infant that failed to grow normally while in the uterus. The infant is not at the expected gestational age. Not the same as SGA.
Kangaroo Care Holding an infant skin to skin.
Large-for-Gestational-Age Infant (LGA) An infant whose size is above the 90th percentile for gestational age. Usually born at term, although they may be preterm or post-term. The preterm LGA infant may be mistaken for full-term but has the same problems as other preterm infants.
Low-Birth-Weight Infant (LBW) An infant weighing less than 2500 g (5 lb, 8 oz) at birth.
Macrosomia Infant birth weight more than 4000 g. Common in diabetic mothers.
Minimal Enteral Nutrition The first feeding, very small amount to help the gastrointestinal tract mature. Also called trophic feedings.
Necrotizing Enterocolitis (NEC) Serious inflammatory condition of the intestinal tract that may lead to cellular death of intestinal mucosa. The ileum and proximal colon are the areas most often affected.
Noncompliance When the lungs resist expansion, they become "stiff".
Parenteral Nutrition Intravenous infusion of all nutrients known to be needed for metabolism and growth.
Periventricular-Inventricular Hemorrage PIVH Bleeding around and into the ventricules of the brain. Most often associated with hypoxic injury to the vessels, increased or decreased blood pressure, and increased or fluctuating cerebral flood flow. Occurs most often in infants < 32 weeks and in the first few days of life. Graded 1-4 according to amount of bleeding. Grade 1 is small bleeding and 4 has poor survival rate.
Postmaturity Syndrome When the placenta is insufficient for the fetus to receive the appropriate amount of oxygen and nutrients. Fetus may be small for gestational age. Can be caused by oligohydramnios or cord compression.
Postterm Infant An infant born after 42 weeks of gestation.
Preterm Infant An infant born before the beginning of the thirty-eighth week of gestation. Also called premature infant.
Pulse Oximetry Method of determining the level of blood oxygen saturation. Nurse should check the pulse oximetry readings frequently for any infant receiving oxygen.
Respiratory Distress Syndrome Condition caused by insufficient production of surfactant in the lungs; results in atelectasis (collapse of the lung alveoli), hypoxemia, and hypercapnia. Occurs most often in preterm infants and increases as the gestational age decreases. Also occurs in birth asphyxia, birth by cesarean, and infants of diabetic mothers.
Retinopathy of Prematurity Previously known as retrolental fibroplasia. Condition in which damage to blood vessels often associated with oxygen use may cause decreased vision or blindness. Occurs more often in premature infants of less than 28 weeks gestation or weighing 1500 g or less.
Small-for-Gestational-Age Infant (SGA) An Infant whose size is below the 10th percentile for gestational age. Infants who are SGA may be preterm, full-term, or post-term.
Transcutaneous Oxygen Monitoring Method of continuous noninvasive measurement of oxygen in the blood by transducers attached to the skin.
Very-Low-Birth-Weight Infant (VLBW) An infant weighing 1500 g (3 lb, 5 oz) or less at birth. Although VLBW are often preterm, they can be full term.

Preterm Infants Overview

Preterm infants are born after 20 weeks gestation and before the beginning of the thirty-eighth week of gestation. Care of very preterm infants causes ethical questions concerning the benefit of saving the baby at a great expense versus the risk that they could have serious, permanent disabilities and little chance to live normal lives. The chance of problems such as blindness, hearing loss, developmental retardation, and cerebral palsy increases as the gestational age decreases.
Causes:
The exact causes of preterm birth are not known. Problems during pregnancy may lead to preterm birth. Multifetal pregnancy is an increasing cause of early birth because of infertility treatments used to achieve pregnancy.
Prevention:
Prevention is best achieved through adequate prenatal care. Promote adequate nutrition and smoking cessation. Teaching woman about signs and symptoms will also allow them to seek medical attention while it is still possible to stop the labor. By the time a woman is dilated 3 cm it is too late to stop labor

Preterm Infant

Common Issues With Nutrition in Preterm Infants

Adequate nutrition is of great importance because the preterm baby did not have time to build up nutrient stores, and the digestive system may not be fully developed. Preemies are lacking calcium, iron and other nutrients. Hypoglycemia is a major concern. The average preterm baby baby should gain 15 to 20 g/kg/day. Protein is digested well, but fat is not absorbed easily. Feeding a preterm infant may include parental feedings (IV), feeding tubes, and oral feedings. The first feeding are enteral or trophic feedings which are administered by gavage with only a few millimeters of breast milk or formula at a time. The preterm infant will have a decreased metabolism of protein and fat. Infants will tire easily, and the suck and swallow are not coordinated until around 32 weeks gestation. Frequent feedings are needed due to the smaller stomach size. The preterm infant will be ready for nipple feedings when they exhibit a gag reflex, have a respiratory rate of less than 60, root, and suck. Preemies need special formulas or fortified breast milk. Formulas contain added calcium, phosphorus, and vitamins.
We all know breast milk is best, but here is a video restating the facts.
The Importance of Breastmilk for Newborns

Breastfeeding is particularly important for preterm infants. Breast milk may increase feeding tolerance, reduce infections and later allergies, enhance neurologic development, and help prevent NEC. Oxygenation levels often are higher during breastfeeding because the infant can regulate breathing and suckling better than with bottle feeding. Nurses should explain these benefits to the mother and encourage breastfeeding. Providing milk for the infant can help the mother feel she has an important role and enhance bonding.

Infant receiving a gavage feeding

Parenting the Preterm Infant

The extended hospitalization of the preterm infant results in separation from parents and may interfere with parenting.

Clinical Signs.

Parental behaviors that may indicate delayed bonding include:
1. Using negative terms to describe the infant.
2. Discussing the infant in impersonal or technical terms.
3. Failing to give infant a name or to use the name.
4. Listing or calling infrequently or not at all.
5. Decreasing the number and length of visits.
6. Showing interest in other infants equal to that in their own infant.
7. Refusing offers to hold and learn to care for the infant.
8. Showing a decrease in or lack of eye contact.
9. Spending less time talking to or smiling at the infant.

Nursing Considerations.

1. Allow the parents to see and touch the infant immediately after delivery if possible.
2. Allow the father or support person to be present for initial care of the infant,if possible.
3. Explain all nursing care, its purpose, and the expected response.
4. Use therapeutic communication techniques to support parents.
5. Prepare the parents for what they will see in the NICU before the first visit(equipment, sounds, how the infant will look).
6. Show parents how to touch the infant appropriately to promote development of attachment.
7. Offer realistic reassurance about the infant's condition.
8. Begin kangaroo care as soon as possible. Place the infant wearing only a diaper and hat, under the mother's clothes between her breasts. Encourage fathers to participate in kangaroo care, too. Kangaroo Care
9. Explain the infant's socialization abilities based on gestational age.
10. Teach parents signs of over-stimulation and signs the infant is ready for more interaction.
11. Involve parents in care as soon as possible. For example the parents can change the baby's diaper and take the temperature.
12. Allow parents to participate in the decisions about the infant.
13. Refer parents to parent groups for contact with other parents of preterm infants.
14. Assess for gradual increase in comfort and participation in care of the infant.
15. Help parents prepare for discharge:
- Give them a copy of the critical pathway, if used.
- Teach medication administration, special procedures, and other care the infant will need after discharge.
- Observe the parents perform care until they feel comfortable and are safe.
- Discuss adaptations necessary in the home for care of the infant.
- Arrange for home nursing services.

Preterm Infant Careplan

Nursing Diagnosis:
Risk for ineffective thermoregulation related to decreased subcutaneous body fat and parental lack of knowledge of newborn thermoregulation abilities and needs.
Knowledge Base:
“Core temperature changes indicate the infant’s thermoregulatory resources are exhausted. Nurses must intervene before this happens.” (Murray, pg. 518)
“Frequent assessment of the patient’s temperature is important to detect patterns of hypothermia.” (Lewis, pg. 390)
Short Term E.O.:
Client’s mother will verbalize three ways to keep baby’s temperature between 97.7° and 99.5° by end of shift on 3/17/09.
Interventions:
1. Nurse will teach mother to keep the baby wrapped as much as possible. (I,E)
2. Nurse will teach mother to dry baby promptly whenever he is wet, such as during bathing and when changing wet diapers or clothing. (I,E)
3. Nurse will instruct the mother to keep the infant’s crib away from cold walls, windows, or drafts from air conditioners and open doors or windows. (I,E)
Rationales:
1. Exposing the skin to the surrounding air increases heat loss by convection and radiation.
(Murray, pg. 517)
2. Heat loss from evaporation occurs when the infant’s skin is wet. (Murray, pg. 517)
3. Heat loss by radiation and convection occurs form exposure to cold objects or air drafts. (Murray, pg. 517)
Long Term E.O.:
Client will maintain a temperature of 97.7° to 99.5° until discharge.
Interventions:
1. Nurse will put the client under a radiant warmer if the client has a low temperature. (I,T)
2. Nurse will apply a cap to the clients head. (I,T)
3. Nurse will wrap the client and expose only small areas of the body at a time when bathing or diapering the client. (I,T)
Rationales:
1. Radiant heat warms infant and can be adjusted according to their needs. (Murray, pg. 517)
2. Covering the head decreases heat loss from the large surface area. (Murray, pg. 517)
3. Exposing the skin to the surrounding air increases heat loss by convection and radiation.
(Murray, pg. 517)

Infant radiant warmer

Objectives:

1. Analyze risk factors that may lead to complications of gestational age and development in the newborn.
Risk factors that cause an infant to be small for gestational age (SGA): congenital malformations, fetal infections from rubella or cytomegalovirus, and chromosomal anomalies. When the placenta malfunctions due to separation or malformation, the baby can be small. Diabetes and preeclampsia in the mother interferes with placental bloodflow and decreases fetal growth. Full term infants who are small for age and can have the same problems as preterm SMA infants. "Problems tend to be greatest in infants who are preterm in addition to being SGA", (Murray, p. 793)

2. Distinguish the special problems of the preterm infant, common nursing diagnoses and nursing care for preterm infants.
respiratory problems: Lungs are under developed. Inadequate surfactant production may lead to respiratory distress syndrome. Nursing care includes assessing for respiratory status, monitoring blood oxygen level and adjusting as needed, placing the infant in a side-lying or prone position to facilitate oxygenation, increasing oxygen before and after suctioning and suctioning gently to avoid trauma.
problems with the skin: The skin is fragile, permeable and easily damaged. Clinical signs include redness, rash, or break in the skin. Nursing care includes assessing the skin frequently for changes, avoiding use of chemicals that may be absorbed or damage the skin, and restricting use of adhesive to prevent damage to the skin. Bathe infant only as necessary. Consider immersion in water for stable infants.
problems with infection: This is caused by lack of passive immunity from the mother, immature immune response, and exposure to hospital organisms. Nursing considerations include having the parent and stuff scrub their hands and arms before handling infants. Teach family members to avoid exposing infant to contagious diseases. Assess for signs of infection to treat early and also response to treatment.
problems with pain: "The nurse must watch carefully for signs of pain and use comfort measures, containment, pacifiers, sucrose, and medications to alleviate it", (Murray, p. 795). Nursing interventions such as heel sticks, venipuncture, intubation can cause pain for infants in the NICU. Although long term effects of pain are not fully understood, the American Academy of Pediatrics suggests that environmental, nonpharmacologic and pharmacologic methods be used to prevent, reduce, and eliminate pain. Pain can be harmful as it raises and or decreases the heartrate, increases intercranial pressure, can raise blood sugar, increase metabolism and the need for oxygen. Signs of pain are: high pitched, harsh crying, and if the baby is too weak to cry they may exhibit a "cry face" without uttering a cry, brow bulge, and eye squeeze. Nursing interventions include: handling the infant minimally before the painful procedure, talking softly, restaining the extremities to prevent flailing, rocking and holding the infant, giving analgesics before the procedure.
problems with fluid and electrolyte balance: Preterm infants lose fluid very easily. Preterm infant's skin is more permeable than the skin of term infants and the large surface area in proportion to body weight increases transepidermal water losses. Radiant and phototherapy lights cause even more fluid loss through the skin. Radiant warmers can cause a 40% to 50% increase in fluid needs. Rapid respiratory rate and use of oxygen increase fluid loss from the lungs. Also, development of the kidneys is not complete until 35 weeks of gestation. The kidneys ability to to concentrate and dilute urine before this time can be poor creating a delicate balance between dehydration and overhydration. Preterm infants also need higher intakes of sodium because the kidneys cannot absorb it well. It is very important to document even the smallest intake or output in the infant. Blood loss from lab draws should be documented and I.V. medications should be diluted in as little fluid as consistent with safe administration and then be included in intake measurements. It is important to weigh all diapers, 1 gram equals 1 ml of urine, and subtract the weight of clean diaper. Specific gravity should be checked to determine if urine is more concentrated or dilute than expected. Signs of dehydration include: Early: decreased urine output(less than 2 ml/hr), increased weight loss, and increased specific gravity. Late: Dry skin or mucous membranes, sunken anterior fontanelle, and poor tissue turgor. Labs: Increased sodium, protein, and hematocrit levels from decreased plasma volume. Signs of over-hydration include: increased output of urine (more than 5 ml/hour), below normal specific gravity, edema and weight gain, bulging fontanels, moist breath sounds. Labs: Low sodium, protein and hematocrit levels. Complications of excess fluid may include patent ductus arteriosus and congestive heart failure. Preterm infants I.V, central venous catheters, or umbilical lines must be assessed every hour for signs of infection, infiltration and position changes.

Common nursing Diagnoses:
Activity Intolerance Risk for Imbalanced Nutrition: less Than body Requirements
Ineffective Airway Clearance Risk for Impaired Parent-Infant Attachment
Ineffective Infant Feeding Pattern Risk for Impaired Parenting
Ineffective Thermoregulation Risk for Caregiver Role Strain
Interrupted Family Processes Risk for Imbalanced Fluid volume
Pain Risk for Impaired Skin Integrity
Risk for Delayed Growth and Development Risk for Infection
Risk for Disorganized Infant Behavior
Risk for Impaired Parent-Infant Attachment
Risk for Impaired Parenting
Risk for Caregiver Role Strain
Risk for Imbalanced Fluid Volume
Risk for Impaired Skin Integrity
Risk for Infection

3. Predict complications that may result from premature birth and postmaturity syndrome.
Respiratory Distress Syndrome, Bronchopulmonary Dysplasia (chronic lung disease), Periventricular Hemorrhage, Petinopathy of Prematurity, and Necrotizing Enterocolitis, affect preterm infants. Postmaturity syndrome is hypoxia and malnourishment in the baby born after 42 weeks. The placenta function decreases and the fetus may not get enough oxygen, amniotic fluid can be decreased, and compression of the umbilical cord may occur. During labor, oxygen may be compromised and the fetus may pass meconium which can be aspirated. "Postterm infants have a higher perinatal mortality rate than infants born at term." (Murray, p. 792) Postterm infants should be assessed for hypoglycemia due to rapid use of the glycogen stores. They may have low temperatures due to fat stores being used for nourishment in utero. The older baby will need early and more frequent feedings. "Polycythemia, resulting from hypoxia before birth, increases the risk of hyperbilirubinemia." (Murray, p. 793)

Sources

Murray, Sharon Smith & Emily Slone Mckinney. Foundations of Maternal-Newborn Nursing. 4th Edition. Sauders Elsevier, 2006.
www.youtube.com/watch?v=MgOCnlKNT8Y&feature=related

QUESTIONS QUESTIONS TEST YOUR KNOWLEDGE QUESTIONS QUESTIONS

1. Choose all that apply when assessing a baby's readiness to nipple feed.
a. absence of gag reflex
b. ability to tolerate holding
c. rooting
d. sucking
e. respiratory rate >60

2.The nurse is developing a plan of care for an infant born at 28 weeks gestation. A realistic goal for this infant is that within 1 week the infant will
a. drink from the bottle
b.recognize parents
c.maintain respiratory rate between 30 and 60 breaths/min
d.maintain body temperature in a bassinet

3.The parent of a preterm neonate ask why their baby gets cold so easily. The nurse explains that preterm neonates
a. are able to shiver to produce body heat
b. have minimal body fat to retain body heat
c. have blood vessels that are deep under the skin surface.
d. lose heat faster beause they lay in a fetal position.

4. A client expresses a desire to breastfeed her preterm infant who is 34 weeks gestation in the neonatal intensive care unit. The nurse should?
a. Support the client's decision and encourage her in her efforts of breastfeeding.
b. Tell the client that breast milk is not easily digested.
c. Discourage the client because breastfeeding is stressful for preterm infants.
d. Tell the client the baby is being fed formula by gavage.

5. A nurse is observing the mother for the infant bonding process. Which of the following observations if made by the nurse would indicate the potential for the lack of the bonding process?
a. Mother is observed talking to the infant.
b. Mother performs cord care for the newborn.
c. Mother requests the nurse to feed the newborn.
d. Mother visits the infant frequently.

6. With a preterm infant, which position is the best for increasing oxygenation?
a. Side-lying
b. Supine
c. Prone
d. Supine with lots of fluffy blankets

7. A 26 week gestation infant is going to receive continuous feeding. What risks are associated? (Select all that apply)
a. Malnutrition
b. Aspiration
c. Bacteria
d. Reflux

8. Which of the following would the nurse expect to assess in a infant delivered at 26 weeks gestation who is diagnosed with perintraventricular hemorrage (PIVH)?
a. Drainage from eyes
b. Hyperbilirubinemia
c. Bulging fontanels
d. Hyperactivity

9. A preterm infant admitted to the NICU at 28 weeks gestation is placed in an isolette. The mother tells the nurse that she is wanting to breastfeed the infant. Which of the following instructions would be most appropriate?
a. Breastfeeding is not recommended because the infant needs increased fat in the diet.
b. Once the infant no longer needs oxygen, breastfeeding can be done.
c. Preterm infants need the added calories of formula to meet their requirements
d. Gavage feedings using breast milk can be given until the infant can coordinate suckling and swallowing.

10. When teaching parents of a preterm infant about kangaroo care in the NICU, the nurse will explain that it is used primarily for
a. freeing up hands to do other activities
b. keeping infants warm
c. providing developmental care
d. a breastfeeding technique

11. The parent's of a 28 week gestation neonate ask the nurse, "Why does our baby have to be fed through a tube in his mouth?" The nurse's best response is that:
a. The baby's stomach cannot tolerate regular formula at this time.
b. The baby will develop thrush, an infection of the mouth, if it were to bottle feed
c. Only feeding through the tube will allow us to accurately determine intake
d. The baby's sucking, swallowing, and breathing are not coordinated yet

12. The most common cause of preterm infant death is respiratory distress, which of the following signs are not involved in respiratory distress?
a. Bradypnea
b. Nasal flaring
c. Decreased breath sounds
d. Cyanosis

13. What statement would indicate to the nurse that her teaching session about preterm infant skin care should be reviewed with the client.
a. I will not bathe my baby everyday, only when it is necessary.
b. I will not dress my baby until she is completely dry.
c. I will use an alcohol swab to remove excess tape from my baby's skin.
d. I will reposition my infant as often as she can tolerate it.

14. Which order would the nurse question regarding care of a preterm infant.
a. Place infant under radiant warmer for axillary temperature less than 97.3 degrees Fahrenheit.
b. Assess IV site every two hours.
c. Reposition infant every two to three hours to promote draining from the dependent areas of the lungs into the main bronchi.
d. Place transparent adhesive dressing over uninfected wound.

15. The nurse is caring for a preterm infant. To promote drainage of secretions the nurse would position the infant:
a. in the Trendelenburg position.
b. in the prone position.
c. in the supine position.
d. in the sitting up position.

16. The nurse is caring for a preterm infant and notes the infant has had urine output > 5 ml/kg/hr, bulging fontanels, edema, and difficulty breathing. The priority nursing intervention would be:
a. check the fluids and current rate of infusion.
b. perform a complete physical assessment.
c. notify the physician.
d. reassess the client in one hour.

17.The mother of a preterm infant is visiting her child in the NICU. She asks if it would be okay to bring her 6 year old twins to visit the new baby. The correct response by the nurse would be:
a. sure they can come anytime to visit!
b. they cannot come and visit the new baby, I'm sorry.
c. they may come to visit during times of care, so we do not disturb your baby's rest.
d. let me call the doctor and ask.

18. The mother of a preterm infant is concerned when her preterm infant has his hands near his face and mouth. "Won't he scratch himself?" The nurses best response would be:
a. This brings comfort to your child, and helps with development.
b. Your right, lets move his hands away from his mouth.
c. I will swaddle the baby tightly to keep his hands at his sides.
d. It's fine, don't worry about it.

Here is a powerpoint presentation with the questions and answers.

wiki questions.ppt